Post-implementation Period Research Articles

Novel expansion of a well-established antimicrobial stewardship program: Enhancing program efficiency and reach.

To evaluate efficiency and impact of a novel antimicrobial stewardship program (ASP) prospective-audit-with-feedback (PAF) review process using the Cerner Multi-Patient Task List (MPTL). Retrospective cohort study. A 367-bed free-standing, pediatric academic medical center. The ASP PAF review process expanded to monitor all systemic and inhaled antibiotics through use of the MPTL on July 23, 2020. Average number of daily ASP reviews, absolute number of monthly interventions, and time to conduct ASP reviews were compared between the preimplementation period and the postimplementation period following expansion. Antibiotic days of therapy (DOT) per 1,000 patient days for overall and select antibiotics were compared between periods. ASP intervention characteristics were assessed. Average daily ASP reviews significantly increased following program expansion (9 vs 14 reviews; P < .0001), and the absolute number of ASP interventions each month also increased (34 vs 52 interventions; P ≤ .0001). Time to conduct daily ASP reviews increased in the postimplementation period (1.03 vs 1.32 hours). Overall antibiotic DOT per 1,000 patient days significantly decreased in the postimplementation period (457.9 vs 427.9; P < .0001) as well as utilization of select, narrow-spectrum antibiotics such as ampicillin and clindamycin. Intervention type and antibiotics were similar between periods. The ASP documented 128 "nonantibiotic interventions" in the postimplementation period, including culture and/or susceptibility testing (32.8%), immunizations (25.8%), and additional diagnostic testing (22.7%). Implementation of an ASP PAF review process using the MPTL allowed for efficient expansion of a pre-existing ASP and a decrease in overall antibiotic utilization. ASP documentation was enhanced to fully track the impact of the program.

Criteria Restricting Inappropriate Meropenem Empiricism (CRIME): a quasi-experimental carbapenem restriction pilot at a large academic medical centre

The broad-spectrum activity of carbapenems makes them appealing for empirical use; however, they are associated with development of Clostridioides difficile infection (CDI) and multidrug resistance. Selective carbapenem use is vital in maintaining their effectiveness. We examined the impact of meropenem restriction criteria on utilisation and patient outcomes. This quasi-experimental study was conducted at a single academic medical centre after medication use evaluation found frequent inappropriate meropenem utilisation. Antimicrobial stewardship-led restriction criteria were developed and implemented in February 2022. Investigators aimed to determine how restriction criteria affected meropenem utilisation across 8 weeks in the pre- (February-April 2020) versus post-implementation period (February-April 2022). The primary outcome was inappropriateness of meropenem utilisation. Secondary outcomes included days of therapy per 1000 patient-days (DOT/1000 PD), hospital length of stay (LOS), CDI Standardized Infection Ratio (SIR), and acquisition cost. Across the 8-week timeframes, reductions in inappropriate meropenem use (64.5% vs. 12.8%; P < 0.001), duration of therapy [5.8 (3.2-7.3) vs. 2.4 (1.0-5.5) days; P < 0.001] and utilisation (30.5 vs. 8.3 DOT/1000 PD; P < 0.001) pre- versus post-implementation were observed. Total meropenem orders decreased by 65% (P < 0.001). Median hospital LOS also decreased between periods [11.9 (7.8-20.4) vs. 9.2 (5.4-15.2) days], although not statistically significant (P=0.051). There was no difference in CDI SIR (0.1 vs. 0.1; P=0.99). Projected annual cost savings were ∼US$57 300. Implementation of antimicrobial stewardship-initiated restriction criteria can reduce inappropriate meropenem utilisation, overall number of orders, and total duration of therapy.

A Multiple Baseline Trial of an Electronic ICU Discharge Summary Tool for Improving Quality of Care.

Effective communication between clinicians is essential for seamless discharge of patients between care settings. Yet, discharge summaries are commonly not available and incomplete. We implemented and evaluated a structured electronic health record-embedded electronic discharge (eDischarge) summary tool for patients discharged from the ICU to a hospital ward. Multiple baseline trial with randomized and staggered implementation. Adult medical-surgical ICUs at four acute care hospitals serving a single Canadian city. Health records of patients 18 years old or older, in the ICU 24 hours or longer, and discharged from the ICU to an in-hospital patient ward between February 12, 2018, and June 30, 2019. A structured electronic note (ICU eDischarge tool) with predefined fields (e.g., diagnosis) embedded in the hospital-wide electronic health information system. We compared the percent of timely (available at discharge) and complete (included goals of care designation, diagnosis, list of active issues, active medications) discharge summaries pre and post implementation using mixed effects logistic regression models. After implementing the ICU eDischarge tool, there was an immediate and sustained increase in the proportion of patients discharged from ICU with timely and complete discharge summaries from 10.8% (preimplementation period) to 71.1% (postimplementation period) (adjusted odds ratio, 32.43; 95% CI, 18.22-57.73). No significant changes were observed in rapid response activation, cardiopulmonary arrest, death in hospital, ICU readmission, and hospital length of stay following ICU discharge. Preventable (60.1 vs 5.7 per 1,000 d; p = 0.023), but not nonpreventable (27.3 vs 40.2 per 1,000d; p = 0.54), adverse events decreased post implementation. Clinicians perceived the eDischarge tool to produce a higher quality discharge process. Implementation of an electronic tool was associated with more timely and complete discharge summaries for patients discharged from the ICU to a hospital ward.

Achievement of nutritional goals after a pediatric intensive care unit nutrition support guideline implementation.

A nutrition support guideline was developed and implemented in a pediatric intensive care unit (PICU) to improve the nutritional management of patients. This study aimed to evaluate the impact of this guideline on achieving energy and protein delivery goals. Medical records of the patients admitted in the PICU from August 2015 to April 2017 were retrospectively reviewed. Patients who stayed in the PICU for less than 24h or had an inborn error of metabolism were excluded. Achievement of nutritional goals was compared between the patients during the pre-implementation period (August to October 2015) and post-implementation period (November 2015 to April 2017) of the guideline. Subgroup analysis by protocol compliance was conducted in the post-implementation group. A total of 215 patients were included in the study (53 pre-implementation, 162 post-implementation). There were no differences between the two groups in patient characteristics, time to start enteral nutrition, time to reach the energy delivery goal, time to reach the protein delivery goal, and proportion of the patients who reached each goal. In the post-implementation group, parenteral nutrition was delayed to three days compared with one day in pre-implementation (p=0.027) and the proportion of patients who did not receive nutrition support was lower (3.1% vs 9.4% pre-implementation, p=0.043). Subgroup analysis in the post-implementation group showed that 69.7% of the patients were protocol compliant, of which the time to reach the energy delivery goal (59 vs 103h, p<0.001) and protein delivery goal (64 vs 135h, p=0.02) were significantly shorter compared with the non-compliant group. Moreover, the proportion of the patients who reached the energy delivery goal (75.2% vs 24.5%, p<0.001) and protein delivery goal (56.6% vs 12.2%, p<0.001) were higher in the compliant group. Compliance with the nutrition support guideline significantly improved the achievements in delivering energy and protein to patients in PICU. Increasing compliance with the guideline may improve clinical outcomes in PICU patients.

Outcomes of Road Traffic Accidents Before and After the Implementation of a Seat Belt Detection System: A Comparative Retrospective Study in Riyadh.

IntroductionRoad traffic accidents (RTAs) are considered a major cause of death in Saudi Arabia. As seat belt compliance provides significant safety among drivers, a camera detection system has been implemented in March 2018 to enforce seat belt utilization, which can decrease the severity of road traffic injuries. There are no previous studies in the country that have assessed the effectiveness of a seat belt camera detection system on the severity of RTA-related injuries.MethodsA retrospective cohort study was conducted at King Abdulaziz Medical Trauma Center in Riyadh, Saudi Arabia. The study included 688 adult patients who were involved in RTAs from the period of March 2016 to March 2020. A data extraction form included sociodemographics, clinical variables, and outcome measures. The data were analyzed using Statistical Analysis Software (SAS) to evaluate the primary outcome measures: mortality, ejection from the vehicle, ICU admissions, and severity measures (injury severity score (ISS) and Glasgow Coma Scale (GCS)) before and after the implementation of seat belt detection system. Associations of the outcome measures in the pre-implementation and the post-implementation periods' seat belt detection were assessed using regression tests.ResultsThere was no significant difference in the mean age between the pre-implementation and post-implementation periods of the seat belt detection system (31.39 years and 32.57 years, respectively). All of the outcome measures have improved following the implementation of the seat belt detection system. Mortality and ejection rates decreased significantly with 58% lower risk of death (OR= 0.42; 95% CI= 0.2,0.8) and 37% lower risk of ejection (OR= 0.63; 95% CI= 0.42,0.94). ICU admissions showed a slight decline in the post-implementation period compared to the pre-implementation period (30.37% vs. 31.37, p<0.7764). Severity measures (ISS and GCS) were slightly improved in the post-implementation period. Head and neck injuries were dominant in the pre-implementation period, and chest injuries were the most common body injuries after the implementation.ConclusionThis study highlights the direct association between compliance with seat belt use and the primary outcome measures among patients who survived a road traffic accident. All of the outcome measures showed improvement in the post-implementation period, which indicates the effectiveness of the newly implemented seat belt detection system. These findings raise awareness to the public in regard to seat belt compliance.

Co-prescription of metoprolol and CYP2D6-inhibiting antidepressants before and after implementation of an optimized drug interaction database in Norway

PurposeTo compare the co-prescription of metoprolol and potent CYP2D6-inhibiting antidepressants before and during a 10-year period after implementation of an optimized drug interaction database into clinical decision support systems in Norway.MethodsThe study was a retrospective, cross-sequential nationwide analysis of drug-dispensing data retrieved from the Norwegian Prescription Database over a 1-year period before (2007) and two 1-year periods after (2012 and 2017) implementation of a drug interaction database providing recommendations on non-interacting alternative medications. Primary outcome was changes in co-prescription rates of metoprolol and the potent CYP2D6-inhibiting antidepressants fluoxetine, paroxetine, or bupropion relative to alternative antidepressants with no or limited CYP2D6 inhibitory potential. To control for potential secular trend bias, a comparison group consisting of atenolol/bisoprolol users was included.ResultsThe co-prescription rate of metoprolol with potent CYP2D6 inhibitors declined following implementation of the optimized database, by 21% (P < 0.001) after 5 years and by 40% (P < 0.001) after 10 years. Compared with atenolol/bisoprolol users, patients treated with metoprolol had significantly reduced likelihood of being prescribed a CYP2D6-inhibiting antidepressant in the two post-implementation periods (OR 0.61 (95% CI 0.54–0.69) and OR 0.45 (95% CI 0.40–0.51), respectively, versus OR 0.84 (95% CI 0.74–0.94) prior to implementation). Small and mostly insignificant differences in average daily metoprolol dosage were found between patients treated with the various antidepressants.ConclusionThe present study suggests that implementation of a drug interaction database providing recommendations on non-interacting drug alternatives contributes to reduced co-prescribing of drug combinations associated with potentially serious adverse effects.

Turnover and Recommendation Intentions in the Post-Implementation Period of Radical Decentralization

Radical Decentralization (RD) is a form of self-management where the authority and decision-making relationship between manager and subordinate is eliminated. A popular RD structure is Holacracy, which pushes decision-making down to the individual employee level. We examined Holacracy adoption within a Canadian technology with 445 employees using a mixed-methods design. We found that the perceived efficacy of RD was contingent on the extent that employees felt there was authentic leadership, efficient administration, role clarity, and role accountability. Perceived efficacy of RD positively predicted employee motivation, which facilitated lower turnover intentions and intent to recommend the organization to others.

Enhancing the quality of prescribing practices for older adults discharged from the emergency department in Rhode Island.

We sought to examine the effectiveness of the Enhancing the Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUiPPED) medication safety program in three emergency departments (EDs) within the largest health system in Rhode Island (RI) with funding through a quality incentive payment by a private insurance partner. This study utilized a quasi-experimental interrupted time series design to implement EQUiPPED, a three-prong intervention aimed at reducing potentially inappropriate medication (PIM) prescriptions to 5% or less per month. We included clinicians who prescribed medications to older ED patients during the pre-and post-intervention periods from July 2018 to January 2021. We determined the monthly rate of PIM prescribing among older adults discharged from the ED, according to the American Geriatrics Society Beers Criteria, using Poisson regression. 247 ED clinicians (48% attendings [n=119], 27% residents [n=67], 25% advanced practice providers [n=61]) were included in EQUiPPED, of which 92% prescribed a PIM during the study period. In the pre-implementation period (July 2018-July 2019) the average monthly rate of PIM prescribing was 9.30% (95% CI: 8.82%, 9.78%). In the post-implementation period (October 2019-January 2021) the PIM prescribing rate decreased significantly to 8.62% (95% CI: 8.14%, 9.10%, p < 0.01). During pre-implementation, 1325 of the 14,193 prescribed medications were considered inappropriate, while only 1108 of the 13,213 prescribed medications in post-implementation were considered inappropriate. The greatest reduction was observed among antihistamines, skeletal muscle relaxants, and benzodiazepines. EQUiPPED contributed to a modest improvement in PIM prescribing to older adults among clinicians in these RI EDs even in the midst of the COVID-19 pandemic. The quality incentive funding model demonstrates a successful strategy for implementation and, with greater replication, could shape national policy regarding health care delivery and quality of care for older adults.

Implementation of Clinical Practice Guidelines for Empirical Antibiotic Therapy of Bacteremia, Urinary Tract Infection, and Pneumonia: A Multi-Center Quasi-Experimental Study.

A quasi-experimental study was conducted on the implementation of locally developed clinical practice guidelines (CPGs) for empirical antibiotic (ATB) therapy of common infections (bacteremia, urinary tract infection (UTI), pneumonia) in the hospitals from January 2019 to December 2020. The CPGs were developed using data from patients with these infections at individual hospitals. Relevant CPG data pre- and post-implementation were collected and compared. Of the 1644 patients enrolled in the study, 808 and 836 were in the pre- and post-implementation periods, respectively, and patient outcomes were compared. Significant reductions in the mean durations of intensive care unit stay (3.44 ± 9.08 vs. 2.55 ± 7.89 days; p = 0.035), ventilator use (5.73 ± 12.14 vs. 4.22 ± 10.23 days; p = 0.007), piperacillin/tazobactam administration (0.954 ± 3.159 vs. 0.660 ± 2.217 days, p = 0.029), and cefoperazone/sulbactam administration (0.058 ± 0.737 vs. 0.331 ± 1.803 days, p = 0.0001) occurred. Multivariate analysis demonstrated that CPG-implementation was associated with favorable clinical outcomes (adjusted odds ratio 1.286, 95% confidence interval: 1.004–1.647, p = 0.046). Among patients who provided follow-up cultures (n = 284), favorable microbiological responses were significantly less frequent during the pre-implementation period than the post-implementation period (80.35% vs. 91.89%; p = 0.01). In conclusion, the locally developed CPG implementation is feasible and effective in improving patient outcomes and reducing ATB consumption. Hospital antimicrobial stewardship teams should be able to facilitate CPG development and implementation for antimicrobial therapy for common infections.

Experimental Implementation of NSER Mobile App for Efficient Real-Time Sharing of Prehospital Patient Information With Emergency Departments: Interrupted Time-Series Analysis.

BackgroundWith the aging society, the number of emergency transportations has been growing. Although it is important that a patient be immediately transported to an appropriate hospital for proper management, accurate diagnosis in the prehospital setting is challenging. However, at present, patient information is mainly communicated by telephone, which has a potential risk of communication errors such as mishearing. Sharing correct and detailed prehospital information with emergency departments (EDs) should facilitate optimal patient care and resource use. Therefore, the implementation of an app that provides on-site, real-time information to emergency physicians could be useful for early preparation, intervention, and effective use of medical and human resources.ObjectiveIn this paper, we aimed to examine whether the implementation of a mobile app for emergency medical service (EMS) would improve patient outcomes and reduce transportation time as well as communication time by phone (ie, phone-communication time).MethodsWe performed an interrupted time-series analysis (ITSA) on the data from a tertiary care hospital in Japan from July 2021 to October 2021 (8 weeks before and 8 weeks after the implementation period). We included all patients transported by EMS. Using the mobile app, EMS can send information on patient demographics, vital signs, medications, and photos of the scene to the ED. The outcome measure was inpatient mortality and transportation time, as well as phone-communication time, which was the time for EMS to negotiate with ED staffs for transport requests.ResultsDuring the study period, 1966 emergency transportations were made (n=1033, 53% patients during the preimplementation period and n=933, 47% patients after the implementation period). The ITSA did not reveal a significant decrease in patient mortality and transportation time before and after the implementation. However, the ITSA revealed a significant decrease in mean phone-communication time between pre- and postimplementation periods (from 216 to 171 seconds; −45 seconds; 95% CI −71 to −18 seconds). From the pre- to postimplementation period, the mean transportation time from EMS request to ED arrival decreased by 0.29 minutes (from 36.1 minutes to 35.9 minutes; 95% CI −2.20 to 1.60 minutes), without change in time trends. We also introduced cases where the app allowed EMS to share accurate and detailed prehospital information with the emergency department, resulting in timely intervention and reducing the burden on the ED.ConclusionsThe implementation of a mobile app for EMS was associated with reduced phone-communication time by 45 seconds (22%) without increasing mortality or overall transportation time despite the implementation of new methods in the real clinical setting. In addition, real-time patient information sharing, such as the transfer of monitor images and photos of the accident site, could facilitate optimal patient care and resource use.

Introducing heart rate variability monitoring combined with biomarker screening into a level IV NICU: a prospective implementation study

The aim of this study was to investigate the association between the implementation of a local heart rate variability (HRV) monitoring guideline combined with determination of inflammatory biomarkers and mortality, measures of sepsis severity, frequency of sepsis testing, and antibiotic usage, among very preterm neonates. In January 2018, a guideline was implemented for early detection of late-onset neonatal sepsis using HRV monitoring combined with determination of inflammatory biomarkers. Data on all patients admitted with a gestational age at birth of < 32 weeks were reviewed in the period January 2016–June 2020 (n = 1,135; n = 515 pre-implementation, n = 620 post-implementation). Outcomes of interest were (sepsis-related) mortality, sepsis severity (neonatal sequential organ failure assessment (nSOFA)), sepsis testing, and antibiotic usage. Differences before and after implementation of the guideline were assessed using logistic and linear regression analysis for binary and continuous outcomes respectively. All analyses were adjusted for gestational age and sex. Mortality within 10 days of a sepsis episode occurred in 39 (10.3%) and 34 (7.6%) episodes in the pre- and post-implementation period respectively (P = 0.13). The nSOFA course during a sepsis episode was significantly lower in the post-implementation group (P = 0.01). We observed significantly more blood tests for determination of inflammatory biomarkers, but no statistically significant difference in number of blood cultures drawn and in antibiotic usage between the two periods.Conclusion: Implementing HRV monitoring with determination of inflammatory biomarkers might help identify patients with sepsis sooner, resulting in reduced sepsis severity, without an increased use of antibiotics or number of blood cultures.What is Known:• Heart rate variability (HRV) monitoring might be used as an early warning system to diagnose preterm neonates at risk of developing sepsis.• It has already been shown that HRV monitoring could reduce mortality; however, there are concerns that HRV monitoring alone could lead to higher rates of blood cultures and overuse of antibiotics.What is New:• Implementing HRV monitoring with determination of inflammatory biomarkers might help identify patients with sepsis sooner, resulting in reduced sepsis severity, without an increased use of antibiotics or number of blood cultures.

A call to action for anticoagulation stewardship

A call to action for anticoagulation stewardship

Antimicrobial Stewardship in Total Joint Arthroplasty: Outcomes of a Collaborative Program Implementation.

Antimicrobial stewardship has been cited as a crucial component of orthopaedic surgical care; however, limited high-quality data exist to guide antibiotic use across the total joint arthroplasty continuum. Antimicrobial stewardship program (ASP) implementation and evaluation is needed in this space. We pursued a prospective, sequential cohort study of an interprofessional ASP for total joint arthroplasty (TJA) formed in late 2017 at the study institution. Twelve total evidence-based recommendations for protocol change were issued, with 11 accepted and implemented across three project phases spanning March 2018 to December 2019. The primary study outcome was the rate of optimal preoperative intravenous antibiotic selection as assessed for Baseline versus Postintervention time periods. Secondary outcomes included individual antibiotic utilization rates. Descriptive statistics were pursued for institutional surgical site infection (SSI) and postoperative acute kidney injury (AKI) rates across the affected time frame. A cost-benefit analysis of the ASP was estimated from the institutional perspective. The rate of optimal preoperative antibiotic selection increased from 64.9% in the Baseline Period (February 2018, n = 57) to 95.4% in the Postimplementation period (June 2018 to December 2019, n = 1,220) (P < 0.001). The rates of second-line preoperative antibiotics and total perioperative antibiotic exposures decreased. Total SSI and AKI rates in primary elective TJA seemed to decrease from calendar year 2018 to 2019 (deep SSI 1.00% to 0.22%, superficial SSI 0.66% to 0.00%, and AKI 1.97% to 1.03%). The institution realized an estimated $197,050 cost savings per 1000 TJA procedures. A comprehensive ASP for TJA was associated with an increased use of optimal preoperative antibiotic selection, decreased total antibiotic exposures, and cost savings, without apparent detriment to SSI or AKI rates.

Impact of Blood Culture Pathway on CLABSI Rates in a Pediatric Cardiac Intensive Care Unit

<h3>Background</h3> Arterial lines, especially in Cardiac Intensive Care Units (CICU) are important in caring for patients. While not central lines, blood cultures are often drawn from them, potentially leading to contamination and over-diagnosis of central line-associated bloodstream infections (CLABSI). Diagnostic stewardship is needed to ensure that correct cultures are obtained, increase the identification of true-positive bacteremia, reduce contamination, and eliminate false-positive CLABSIs. <h3>Methods</h3> A retrospective review was performed to determine effects of a clinical work pathway (CWP) on blood culture practices and CLABSI rates in a 12-bed pediatric CICU from August 1st, 2019, to July 31, 2021. A multidisciplinary and multi-unit team developed a blood culture pathway in August 2020 discouraging culturing of often colonized arterial lines in favor of peripheral venous draws. The primary outcome was the total number of arterial line cultures collected per 100 patient-days. The secondary outcomes were the National Healthcare Safety Network standardized infection ratio (SIR) for the unit and the CLABSI rate per 1000 device-days. <h3>Results</h3> In the pre-intervention period, 763 blood culture were sent over 4316 patient days. For the post-intervention period, 632 cultures were sent over 5151 patient days. CICU had 981 additional device days in the post-period as compared to the pre-intervention period. Arterial line cultures decreased significantly from 3.99 arterial line cultures/100 patient days to 0.29 cultures/100 patient days (p< 0.001). The SIR went from 2.428 to 2.107 between the pre- and post-implementation period. The CLABSI rate decreased from 3.13 infections/1000 device days to 2.71 infections/1000 device days. <h3>Conclusions</h3> Standardization of blood cultures in the CICU decreased the number of arterial line cultures and contributed to a reduction in the SIR and CLABSI rate. The impact of the COVID-19 pandemic on blood culture practices is unclear although higher patient acuity was evident by the increase in device days post implementation of the CWP.

Public-Private Partnerships: Exploring Perceptions and Efficacy of Community Security Patrols

This paper explores how one large police agency entered into a public-private partnership with a private security firm to supplement police power and presence in two diverse, high-crime neighborhoods. Using a quasi-experimental design, the researchers found road patrol in marked security vehicles produced significant decreases in Part I and II crimes in the pre-and post-implementation periods. Further, surveys of residents revealed that after the completion of the project, citizens had more positive perceptions of the police, believed that crime had declined, and reported lower fear of crime.

Impact of Pharmacist-Led Implementation of a Community Hospital-Based Outpatient Parenteral Antimicrobial Therapy on Clinical Outcomes in Thailand.

Few studies have analyzed community hospital-based parenteral anti-infective therapy (CohPAT). We aimed to assess the clinical impact of a pharmacist-led implementation of a clinical practice guideline (CPG) for CohPAT, and to determine the pharmacist’s role in CohPAT medication management. The prospective-period patients (post-implementation group) were compared with the historical control-period patients (pre-implementation group) for receiving a continuous antimicrobial parenteral injection. A CPG was used for laboratory testing for efficacy and safety, the monitoring of adverse drug events during admission, microbiology results coordination, and dosage adjustment. For any antimicrobial drug-related problems, the pharmacist consulted with the clinicians. Over 14 months, 50 participants were included in each group. In the pre-implementation period, 7 (14%) and 4 (8%) out of 50 patients received an inappropriate dosage and nonlaboratory monitoring for dose adjustment, respectively. The patients received the proper dosage of antimicrobial agents, which increased significantly from 78% pre- to 100% post-implementation (p = 0.000). The pharmacist’s interventions during the prospective-period were completely accepted by the clinicians, and significantly greater laboratory monitoring complying with CPG was given to the postimplementation group than the pre-implementation group (100% vs. 60%; p = 0.000). Significantly less patients with unfavorable outcomes (failure or in-hospital mortality) were observed in the post-implementation than in the pre-implementation (6% vs. 26%; p = 0.006) group. For the logistic regression analysis, lower respiratory infection (adjusted OR, aOR 3.68; 95%CI 1.13–12.06) and the post-implementation period (aOR 0.21; 95%CI 0.06–0.83) were significant risk factors that were associated with unfavorable outcomes. Given the better clinical outcomes and the improved quality of septic patient care observed after implementation, pharmacist-led implementation should be adopted in healthcare settings.

Impact of an interdisciplinary goals of care program on hospital outcomes at a comprehensive cancer center during the COVID-19 pandemic: A propensity score analysis.

6502 Background: Many hospitals have established goals-of-care (GOC) programs in response to the COVID-19 pandemic; however, few have reported their outcomes. MD Anderson Cancer Center launched a multicomponent interdisciplinary GOC (myGOC) program in March 2020 that involved risk stratification, team huddles to discuss care planning, oncologist-initiated GOC discussions, communication training, palliative care involvement, rapid-response GOC team deployment, and daily monitoring with immediate feedback. We examined the impact of this myGOC program among medical inpatients. Methods: This single-center study with a quasi-experimental design included consecutive adult patients with cancer admitted to medical units at MD Anderson Cancer Center, Texas during an 8-month pre-implementation (May 1, 2019 to December 31, 2019) and post-implementation period (May 1, 2020 to December 31, 2020). The primary outcome was intensive care unit (ICU) mortality. Secondary outcomes included ICU length of stay, hospital mortality, and proportion/timing of patients with in-hospital do-not-resuscitate (DNR) orders, medical power of attorney (MPOA), living will (LW) and out-of-hospital DNR (OOHDNR). Propensity score weighting was used to adjust for differences in potential covariates, including age, sex, cancer diagnosis, race/ethnicity, and Sequential Organ Failure Assessment (SOFA) Score. With a sample size of 600 ICU patients over each time period and a baseline ICU mortality of 28%, we had 80% power to detect a 5% reduction in mortality using a two-tailed test at 5% significance level. Results: This study involved 12,941 hospitalized patients with cancer (Pre n = 6,977; Post n = 5,964) including 1365 ICU admissions (Pre n = 727; Post n = 638). After myGOC initiation, we observed a significant reduction in ICU mortality (28.2% vs. 21.9%; change -6.3%, 95% CI -9.6, -3.1; P = 0.0001). We also observed significant decreases in length of ICU stay (mean change -1.4 days, 95% CI -2.0, -0.7 days; P &lt; 0.0001) and in-hospital mortality (7% vs. 6.1%, mean change -0.9%, 95% CI -1.5%, -0.3%; P = 0.004). The proportion of hospitalized patients with an in-hospital DNR order increased significantly from 14.7% to 19.6% after implementation (odds ratio [OR] 1.4, 95% CI 1.3, 1.5; P &lt; 0.0001) and DNR was established earlier (mean difference -3.0 d, 95% CI -3.9 d, -2.1 d; P &lt; 0.0001). OOHDNR (OR 1.3, 95% CI 1.1, 1.6, P &lt; 0.0007) also increased post-implementation but not MPOA and LW. MPOA, LW and OOHDNR were documented significantly earlier relative to the index hospitalization in the post-implementation period (P &lt; 0.005 for all). Conclusions: This study showed improvement in hospital outcomes and care plan documentation after implementation of a system-wide, multicomponent GOC intervention. Our findings may have implications for GOC programs during the pandemic and beyond.

Time to biopsy of screening mammography-detected abnormalities: Evaluating the impact of same-day services implemented during the COVID-19 pandemic.

1511 Background: Screening mammography programs often require patients undergo multiple visits (screening exam, diagnostic exam, and biopsy) before tissue diagnoisis of screen-detected abnormalities. During the COVID-19 pandemic, same-day breast imaging services were leveraged to decrease the number of visits following abnormal screening exams. Specifically, in May 2020, we implemented an immediate-read screening mammography program to synergize with our pre-existing same-day breast biopsy program, such that every effort was made to perform diagnostic imaging during the same visit after an abnormal screening mammogram. This study aims to evaluate the impact of these same-day breast imaging services on time and number of patient visits to undergo breast biopsy after an abnormal screening mammogram. Methods: Consecutive screening mammograms performed during normal business hours pre- (6/1/16 to 5/30/17) and post-implementation (6/1/20 to 5/30/21) of same-day services were identified. Patient demographics, imaging and biopsy results, and visit dates were extracted from the medical record. Multivariable logistic, linear, and ordinal regression models estimated with generalized estimating equations were fit to assess the association of period (pre- versus post-implementation), patient age, and race and ethnicity (White versus races other than White) with having a same-day biopsy (biopsy on the same day as the abnormal screening exam), number of days to biopsy, and number of visits. Adjusted odds ratios (aOR) and beta estimates (aBeta) of each covariate and corresponding 95% confidence intervals (CI) were estimated. Results: A total of 409/25,922 (1.6%) of patients (median age 61, IQR 50-70) pre-implementation and 221/20,452 (1.1%) patients (median age 62, IQR 49-71) post-implementation had screen-detected abnormalities leading to diagnostic breast imaging and biopsy. Median number of days from screening to biopsy decreased from 16 days pre-implementation to 5 days post-implementation (p &lt; 0.001). Pre-implementation, 86.8% of patients required 3 visits between screening and biopsy, while post-implementation only 23.1% required 3 visits (p &lt; 0.001). Compared to pre-implementation, the post-implementation period was associated with increased odds of undergoing same-day biopsy (aOR 20.7, 95% CI 8.3-51.7), p &lt; 0.001), fewer days from abnormal screening mammogram to biopsy (aBeta -13.3, 95% CI -15.7 to -10.9, p &lt; 0.001), and fewer visits (aOR 0.05, 95% CI 0.02-0.09), p &lt; 0.001), controlling for age and race and ethnicity. Conclusions: Same-day breast imaging services decreased time and patient visits between abnormal screening mammogram and breast biopsy. Same-day services implemented out of necessity during the COVID-19 pandemic should be continued after the pandemic has subsided to improve timeliness of care.

Evaluation of an oral care bundle for reduction of nonventilator hospital-acquired pneumonia in a community hospital

Objectives: We sought to determine the relationship between an oral-care bundle that includes use of new oral care devices, education of best practices for performing oral care, and daily audits to measure compliance with oral care best practices and the reduction of nonventilator hospital-acquired pneumonia (NV-HAP) and NV-HAP–associated sepsis and mortality outcomes. Methods: Havasu Regional Medical Center (HRMC) is a 171-bed acute-care community hospital in Lake Havasu City, Arizona. The hospital inpatient units measured in this quasi-experimental study were the medical surgical telemetry ortho unit (MTSO), the intermediate care unit (IMC), and the ICU.There were 30,838 hospital patient days in 2021. NV-HAP were captured as patients coded as an NV-HAP and being discharged in 2021. Sepsis was captured as sepsis being documented with the source being identified as a NV-HAP with a discharge date in 2021. Mortality was captured by coding of an NV-HAP and mortality with a time of death documented in 2021. Results: From January 1, 2021, to June 4, 2021, during the baseline period before the oral-care bundle was implemented, HRMC had 12,415 patient days and experienced a NV-HAP rate of 1.2 per 1,000 patient days and a sepsis rate of 0.56 per 1,000 patient days with the source documented as NV-HAP, and mortality rate of 0.32 per 1,000 patient days with a code of NV-HAP. HRMC used June 5, 2021, as their implementation period of the bundle, which included a new oral-care device, multilevel education to staff on best practices for oral care, and daily audits to measure compliance with oral-care best practices. During the postimplementation period, HRMC had 18,413 patient days, a NV-HAP rate of 0.54 per 1,000 patient days, a sepsis rate of 0.33 per 1,000 patient days with source documented as NV-HAP, and a mortality rate of 0.16 per 1,000 patient days with a code for NV-HAP. Conclusions: From June 5, 2021, to December 31, 2021, after the implementation of the oral-care bundle, the NV-HAP rate decreased by 58%, the sepsis rate with source documented as NV-HAP decreased by 41%, and the morality rate documented as NV-HAP decreased by 50%. Hospital infection control programs should consider implementation of a robust oral-care bundle that includes best-practices education and auditing to monitor staff compliance as a potential strategy to reduce NV-HAP.Funding: NoneDisclosures: None

MHPAEA/ACA Policy Implementation and Severe Maternal Morbidity Among Commercially Insured Individuals, 2008–2019 [A192

INTRODUCTION: We aimed to identify rates and trends in severe maternal morbidity (SMM) in relationship to implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) and Affordable Care Act (ACA). METHODS: We conducted a serial, cross-sectional analysis among individuals with continuous commercial coverage in the year preceding and following an inpatient livebirth using data from Optum Cliniformatics Data Mart. We identified hospital deliveries and cases of SMM using standard methods. We excluded cases of SMM in which blood transfusion represented the only indicator of SMM. We evaluated rates and trends in SMM in both the implementation (2008–2014) and post-implementation (2015–2019) periods using an interrupted time-series model fit with generalized estimating equations for the overall population and compared those with and without perinatal mood and anxiety disorders (PMAD). The University of Michigan Institutional Review Board deemed this study exempt from review. RESULTS: The sample included 681,616 births. SMM decreased by 53.2% from 195.8 (95% CI, 188.1–203.3) to 91.6 (95% CI, 85.7–97.6) per 10,000 hospitalizations for birth between 2008 and 2019. We identified decreasing SMM rates in both periods, with a larger decrease in the post-implementation period (implementation marginal effects [ME], −0.0012; post-implementation ME, −0.0015; P&lt;.001). We observed decreasing SMM rates in both periods for those with and without PMAD, with the steepest decline among those with PMAD in the post-implementation period. CONCLUSION: These data suggest that implementation of the MHPAEA and ACA may have had a role in decreasing rates of SMM among childbearing individuals with commercial insurance.